早期介入對於早產兒之親子互動與發展預後的療效: 臨床隨機實驗

Abstract

第一章 親子互動品質可能與生理(如出生狀況)及環境因素有關(如父母的情緒)，早產兒出生後由於各系統不成熟，且父母的壓力大，其親子互動中的表現是否與足月兒有異，甚而因此影響到後來的發展，相當值得深入探討。本論文的目的在回顧過去早產兒親子互動的文獻，並探討早產兒及其母親的互動行為、親子互動對於早產兒後續的發展影響、理想的親子互動模式以及提供親子互動衛教的早期介入對於早產兒發展的介入效果。綜合文獻資料顯示，早產兒的母親比足月兒的母親較常出現負面的互動行為，例如過度的控制行為、低敏感度和低反應。而且，這些負面的互動行為與早產兒的不利發展 (如認知、語言和行為表現)具有相關。至於提供親子互動衛教的早期介入研究則顯示，對於早期母親互動行為具有療效的介入方式同時也能帶來後續的發展預後提昇。總結而言，以上的資料提供重要訊息以幫助了解早產兒親子互動，未來的研究需探討何種親子互動模式的介入能為早產兒帶來更大的發展效益。

第二章 目的：本研究的目的在檢驗早期介入對於極低出生體重早產兒之親子互動和發展預後的療效，並且探討親子互動是否會影響發展預後的療效。方法:166名極低出生體重早產兒被納入此臨床隨機實驗中(門診介入組：n=55；家訪介入組：n=58；常規組：n=53)，門診和家訪介入組的介入治療會由住院期開始至矯正年齡12個月。親子互動於嬰孩矯正年齡6、9和12個月時使用自由玩耍的方式來評估互動的品質，嬰兒發展則於矯正年齡24個月時使用貝萊氏嬰幼兒發展評估工具第三版以評估認知、語言和動作發展。結果：門診介入組的母親比常規組的母親較常使用高品質的互動行為(9個月：差異[95%信賴區間] = 10% [-1%至21%]，p = 0.08；12個月：差異[95%信賴區間] = 10% [-1%至22%]，p = 0.07)。矯正年齡24個月時，門診介入組比常規組的早產兒有明顯較高的認知分數(差異[95%信賴區間] = 6.1 [0.9至11.4]，p = 0.03)和較低的動作遲緩發生率(勝算比[95%信賴區間] = 0.2 [0.04至1.1]，p = 0.06)。多變項迴歸分析顯示把12個月時母親高品質互動行為放進迴歸方程式後，明顯降低了門診介入與認知發展間的相關性，但對於介入與動作遲緩的相關性則無改變。至於家訪介入組則在親子互動和發展預後方面均未呈現明顯的療效。結論：早期介入(尤其是門診介入)有利於極低出生體重早產兒於出生後兩年內的親子互動品質和認知與動作發展預後，而且早期的母親互動行為改善似能部份解釋其孩童認知發展預後的療效。

Chapter 1 The quality of mother-infant interaction in preterm infants may be associated with biological (e.g., perinatal condition) and environmental factors (e.g., parental emotion). Due to biological immaturity and high parental stress, it is crucial to elucidate whether preterm infants differ from term infants in the quality of mother-infant interaction that results in subsequent adverse developmental outcome. The purpose of this paper was therefore to review previous studies regarding parent-infant interaction associated with preterm birth, particularly focusing on the mother-infant interactive behavior in preterm and term infants, the impact of maternal interactive behavior on preterm infants’ development, the optimal model of mother-infant interaction, and the effectiveness of mother-infant interaction education on preterm infants’ developmental outcome. The results showed that negative maternal interactive behaviors, such as more controlling, less sensitivity and less response, more often occurred in preterm infants than in term infants. These negative interactive behaviors were found to associate with later adverse development (e.g. cognitive, language and behavior) in preterm infants. Several intervention studies showed positive effects on early maternal interactive behavior and later child development. In summary, the findings provide important information to help understand the mother-infant interaction associated with preterm birth. Future study needs to investigate what style of mother-infant interaction intervention will best benefit child development.

Chapter 2 Objective: To examine the effectiveness of early intervention on mother-infant interaction and developmental outcome in very low birth weight (VLBW) preterm infants; and to investigate whether mother-infant interaction influenced the intervention effect on developmental outcome. Methods: This randomization control trial included 166 VLBW preterm infants (clinic-based intervention program [CBIP]: n=55; home-based intervention program [HBIP]: n=58; usual care program [UCP]: n=53) in the experimental and follow-up period. The CBIP and HBIP commenced in hospitalization and ended at 12 months of corrected age (CA). Mother-infant dyads were examined the quality of interaction in free play at 6, 9 and 12 months CA. Infants were assessed their cognitive, language and motor development at 24 months CA using the Bayley Scales of Infant and Toddler Development-3rd edition. Results: The CBIP group mothers more frequently used high-quality interactive behavior in free play than the UCP group mothers during the experimental period (9 months: difference [95% CI] = 10% [-1% to 21%], p = 0.08; 12 months: difference [95% CI] = 10% [-1% to 22%], p = 0.07). Subsequently, the CBIP group infants showed better cognitive performance (difference [95% CI] = 6.1 [0.9 to 11.4], p = 0.03) and lower incidence of motor delay (odd ratio [95% CI] = 0.2 [0.04 to 1.1], p = 0.06) than the UCP group infants at 24 months CA. Inclusion of the maternal interactive behavior at 12 months CA in the multivariate regression model had significantly attenuated the relation of intervention (CBIP) with cognitive outcome but did not influence intervention effect on motor outcome. In contrast, the maternal interactive behavior and child developmental outcomes did not vary between the HBIP and UCP groups. Conclusions: Early intervention, specifically the CBIP, was beneficial for the mother-infant interaction and cognitive/motor outcome in VLBW preterm infants during the first two years of age. Early maternal interactive behavior might mediate the intervention effect on their cognitive outcome.